说到这里，想起最近一个好朋友的妈妈过世了，我不停在担心她的表现（太坚强），会不会是没有和自己的情绪接触(not in touch with her emotions)。毕竟东方国家，从小就被教育把负面情绪压抑，从来没有机会感受和接受。这个女生，也给我一样的感觉，总是“美美的”，没有什么表情，她的情绪起伏不大，笑容很浅，说到自己最难过的事情，也只掉了一点泪，就算我说，可以哭，可以难过，可以和这个情绪感觉相处…

Most people know that Exposure Response Prevention (ERP) is the main intervention used for Obsessive Compulsive Disorder (OCD). So the rationale is pretty simple here, say we have a patient who is afraid of contamination (obsession) and wash his hands excessively (compulsion), we do some preparation work and can then start the ERP by exposing him to dirt without letting him to wash his hands (response prevention). This is normally done on a very gradual manner (with the patient’s consent and enough preparation work beforehand, so it is definitely not forcefully done to him). And of course in reality the OCD cases are barely as straightforward and simple as this, but this is the general principle.

With pure obsession, i.e. those without any compulsive behaviour, it’s all in their minds, things can get a bit harder, but still, it’s possible. Some commonly seen pure-O are (1) relationship obsessions (discussed in my blog else where as “morbid jealousy” which might or might not be the same condition), (2) sexual obsessions, (3) religious obsessions, (4) violent obsessions, (5) neutral obsessions.

So let’s take a recently seen man as an example here. It started once when he drove past a church, and somehow a sexual related thought popped out in his mind, he couldn’t bear himself having such “dirty” thought in a holy place, and since then, whenever he goes passed any holy places, he will suppress his mind from coming out with any “dirty thoughts”. And as we all know that our minds don’t work this way, the more you try to push some thoughts away, the more they bounce back and pop up.

ERP is possible for such pure-O cases. After the initial preparation work including psychoeducation, motivation building and mindfulness training, they are exposed to those thoughts that they have been avoiding, in those places (based on the items in the hierarchy). So it works similarly for all different types of pure obsessions, be it relationship, violent, religious or sexual (in certain cases where direct exposure is not possible, it will have to be done in imagination, and by watching videos etc).

However, how about neutral obsessions? What the patient has could be some really simple, random thoughts, which might be inconsistent, but they might be spending hours and hours thinking about these random stuff. Like a young man I saw couple months ago, who reacts to any thought his mind comes up with, e.g. “why does the universe work this way?”, “how do my ears listen and my brain comprehend what others say?” etc. I couldn’t really carry out typical ERP to him, since those are really random topics and they can be completely different every time. So I needed him to start thought defusion exercises, mindfulness meditation (then he dropped out…). I believe this is the best way for neutral pure-O, though I understand how difficult it’s to increase their motivation to keep practicing until they see the effects (did have patients in the past who were surprised by how quiet their minds can be after such exercises – and this is just a bonus, as it’s not the intention or purpose of such practices).

Do enlighten me if you have better psychological intervention for neutral pure-O. And I hope all the OCD sufferers out there will not give in to the illness!

回到主题，最后Dr Chung不再和其他人联络/接触，情绪崩溃，独自走上末路（其实他有没有死，结局没有交代）。这其实对我而言，或多或少地确认了我的判断，他是悲悼过度而抑郁。如果你只是悲悼，一般不那么抗拒周围的人，你还是可以继续生活、工作或学习等，并接受其他人的陪伴，但是哀悼与抑郁的一线之差(really just a fine line!)，在于你开始抗拒其他人，开始封闭自己（有一幕他的警擦朋友和社工朋友说已经很久没有看到他了，另一精神科医生好朋友也已经反目成仇）。

The girl has been housebound for several months now. Though she managed to come to the clinic, but was seemingly restless and anxious, pacing the floor in the waiting area. She couldn’t see people using smartphones anywhere near her. She would think people are taking her pictures and use them for detrimental purposes. When she is in such situation, she experiences strong urges to grab the phone from others.

She does recognise those intrusive thoughts as irrational and could restrain herself from doing so. But like many other with OCD, she is staying home more and more to avoid such situations. When she first consulted a psychiatrist, it was about two years ago. She was quiet, introverted, sensitive, and repetitive in her speech, but wasn’t diagnosed as having OCD.

To really consider her current presentation, she seems to be having persecutory delusions (a common form of delusion in paranoid schizophrenia, where the person believes that ”he or she is being tormented, followed, tricked, spied on, or ridiculed.”).

So, how do you know or decide the diagnosis? Is it OCD or is it borderline psychotic of sorts?

Looking at the backgrounds, the mother who came with her said that she (the mother) has been “depressed” and taking psychiatric drugs for the past 10 years, it was mainly due to the stress caused by her daughter (only child). Though one of the mother’s symptoms, is compulsive washing(!), fear of contamination. It’s not difficult to imagine some OCD can be so severe and disabling leading to depression (the comorbidity rate is high anyway). But here through the mother at least a family history of OCD is exhibited.

In DSM-5, it is specified that OCD may be seen with: (i) good or fair insight, (ii) poor insight, or (iii) absent insight/delusional beliefs. In all previous editions of the DSM, the criteria for the diagnosis of obsessive-compulsive disorder included the sufferer’s realization that their obsessions and compulsions are irrational or illogical. Now, absent insight/delusional beliefs can be part of an OCD diagnosis. Though we have all noticed that OCD sufferers’ levels of insight can change quickly, often depending on the circumstances and situations (e.g. the intrusive thought was felt completely real when she’s in the public noticing someone holding the phone VS when she’s at home thinking about that situation).

Some psychiatrists would prescribe both anti-depressants (serving as anti-OCD) and anti-psychotics. However, there were cases where OCD patients were first misdiagnosed as psychotic, and taking anti-psychotic very much worsened their OCD (though once they stopped the anti-psychotics and took anti-depressants at the right dosage, their OCD symptoms alleviated).

So time spent for detailed psychopathology and specific diagnosis would be of greatest importance. The presentation of suspiciousness (paranoia) as the main symptom suggested possibility of psychosis, however, the repetitive nature of the thought, which was stereotyped, causing severe distress, also the family history of OCD, pointed toward a greater possibility of obsessions. What is more difficult with this case is the absence of compulsions and reassurance seeking. And my final point, it’s not necessarily “either or”, it could be both! But still it takes much time and effort to really work that out.

I was recently having a conversation in the clinic and a patient back in the time when I was working in North London Forensic Service popped up in my mind. This is a big black man with a diagnosis of schizophrenia, he also assaulted his ex girlfriend and hence was in the inpatient security ward that I worked at.

From day one I met this man, he was in good order and discipline, never exhibited any of the psychotic symptoms, abusive language or aggressive behaviour of any sort, unlike many other patients there. He was also doing an MBA course through the Open University. So most of the staffs in the team believed that he would make his way out soon, to the community, starting a new life. However, his stay was extended. To our surprise, it was due to a note recorded by a nursing staff (what each patient does every day is recorded on every shift). The nurse got along quite well with the patient, on one occasion, the patient shared with the nurse his experience of seeing white light in his room coming from the sky, and an angelic human coming to him and passing him some positive messages.

The patient surely didn’t know this was recorded in the note. However, this was used against to the patient in the court as evidence of him still experiencing psychotic symptoms (both visual hallucination and delusion) and was not well enough to leave the ward to the community. The patient came to know the details only after the hearing, from his solicitor. He didn’t get to defend himself on his experience, which he later expressed that this was completely a religious experience, which he found amazing and intriguing, and in no way is related to mental illness. He came from a very religious family.

This was at least 4 to 5 years ago. I still remember it because until today I still cannot be sure whether that decision made by the team was correct. I am not a religious person (few years ago I was turned down as a volunteer in an NGO because I told the interviewer that I have no religion!), I can’t truly understand how a very religious person’s experience with god is like. I did complete the Alpha course in the church when I was doing postgraduate in Brighton. I met a lot of very nice persons, some I still keep in touch today. Sometimes I could be quite shocked by their presentations and behaviour during the services, but I respect that it’s their belief, and I learnt from them although I have not experienced it at all.

If it was a so-called normal person experiencing and sharing their religious or cultural experience, we might or might not believe them, but we wouldn’t think they are having hallucinations. How if a religious person with a history of mental illness experienced and shared such encounter? This is like when I worked there, sometimes we had to do night shifts, and many of those African nurses wouldn’t stay on the ward alone no matter what (we shouldn’t anyway, but there are times of emergency etc). They have had so many encounters of “ghosts” and “spirits” and scary stuff, it’s a hospital afterall, it’s easily linked to deaths (and then “ghosts”). But when this was expressed by a patient, even the African nurses would suspect that he was just having hallucination!

I can’t really have any say about these, I have experienced none, spiritual, religious, or thrilling (to be honest I’m happy and keen to experience them). We were told that we should pay attention to cultural influences and backgrounds before we “judge” someone diagnose a patient. It’s true, I now think it was wrong to hold the big man back solely based on that.